Now, picture the same clinic where payments are processed automatically, adjustments are clear and transparent and everything fits together like a well-oiled machine. That is the magic of ERAs.

In this blog we will learn what is ERA in medical billing and how its helps healthcare providers in cutting the gaps between payment processing and final transactions.

What is ERA In Medical Billing?

An Electronic Remittance Advice (ERA) is the electronic format of file 835. It contains the claim details and essential documents related to payments like claim status, benefits coverage. Insurance providers usually issue ERAs to healthcare providers.

According to adopted transaction standards and operating rules, an ERA is federally mandated for all HIPAA covered entities using electronic transactions such as healthcare plans, clearinghouses and healthcare organizations.

The ERA is transmitted in a HIPAA compliant ANSI X12 5010 format. Providers enrolled for 835/ERA are not eligible to receive Paper Remittance Advice by mail.

Standard Codes Used in ERA to Identify Adjustments

Providers can create the EOB as an electronic file, usually in a format called an 835, and can download the ERA 835 file from the clearinghouse.

The insurance providers itemize the claim details and status within an ERA. This itemized information helps providers to adjudicate with the claims.

The ERA explains the reason and value of each adjustment.  Adjustments appear claim wise or at a provider level at a line. Three standard codes identify the adjustment reasons in an ERA.

These codes are:

1. Claim Adjustment Group Code (Group Code)
2. Claim Adjustment Reason Code (CARC)
3. Remittance Advice Remark Code (RARC)

Claim Adjustment Group Codes (Group Code)

Claim Adjustment Group Codes (Group Code) indicate and assign the responsibility of claim adjustment in the EOB. It comprises two alpha characters.

There are five Claim Adjustment Group Codes.

These include:

1. Contractual Obligation (CO)
2. Corrections and Reversal (CR)
3. Other Adjustment (OA)
4. Payer Initiated Reductions (PI)
5. Patient Responsibility (PR)

It is worth mentioning that Medicare beneficiaries may be billed only when Group Code PR is used with an adjustment.

Claim Adjustment Reason Codes (CARCs)

The Claim Adjustment Reason Codes (CARCs) as name shows explain the reasons for the difference or mismatch in claims or services than they billed.

These codes are the standard way to transmit the information about adjustments made to a medical claim or a service.

The main objective of these codes is to provide a clear justification for any inaccuracy or a mismatch between the amount billed by the insurance provider and the amount billed by the healthcare provider.

Remittance Advice Remark Codes (RARCs)

Remittance Advice Remark Codes (RARCs) provide further details to an adjustment that is already explained by a CARC or to transfer information about remittance processing. Each RARC explains a specific message as given in the Remittance Advice Remark Code List.

Levels/Segments of an ERA

 The electronic remittance advice (ERA) contains three levels.

1. Header
2. Details
3. Remark

The items in the data record that contain ERA information are called segments, which are found in each ERA level.

An ERA’s general organizational structure is shown in the table.

How ERA Assists Providers in Payment Processing?

No doubt, utilizing innovative and cutting-edge solutions in healthcare can significantly benefit both providers and patients.

The electronic remittance advice (ERA) has made things more convenient for healthcare providers when they execute the payments workflow with payers.

Here are some major benefits of ERAs, how they help providers:

Minimizes Manual Processes

Traditional payment methods often involve cumbersome manual handling of documents such as Explanation of Benefits (EOB) statements, which are prone to errors and delays.

ERAs automate this process by electronically generating and transmitting these statements. This not only reduces the need for manual data entry but also minimizes the risk of lost or misplaced documents. 

Providers can efficiently process ERAs through their practice management systems, automate posting payments, and apply standard adjustment reason codes directly to patient accounts. This reduces operational costs, saves time, and optimizes resource utilization, allowing staff to focus on more critical tasks.

Fast and Accurate Payments

ERAs significantly accelerate the payment process, leading to quicker and more accurate payments compared to traditional methods.

This improved speed can boost collections; reduce claim denials, and lower paper-related costs.

Enhanced payment accuracy and faster processing times contribute to smoother financial operations and improved overall productivity within healthcare practices.

Cuts Administrative Costs

By automating the billing and remittance process, ERAs reduce the administrative burden on healthcare staff.

The decreased need for manual paperwork allows staff to allocate more time to patient care.

Furthermore, ERAs help minimize human errors, which in turn reduces the frequency of claim denials and rejections, streamlining administrative tasks and improving overall efficiency.

Improved Patient Satisfaction

The efficiency brought by ERAs translates into a better billing experience for patients.

Faster, more accurate payments and clearer explanations of charges enhance billing transparency.

This improved communication not only builds trust but also fosters patient satisfaction and loyalty, positively influencing the patient-provider relationship.

Enhanced Workflow Efficiency

ERAs integrate seamlessly with revenue cycle management software, simplifying the payment process.

By eliminating the need for manual data entry into multiple systems, ERAs help reduce errors and save valuable time for billing staff.

Real-time access to ERA data enables healthcare practices to efficiently track claims, promptly address any issues, and maintain a smooth workflow.

Optimized Revenue Management

ERAs facilitate the swift identification of discrepancies in payments from insurance companies, ensuring accurate and full reimbursement.

Effective tracking of claim statuses and timely follow-ups on denied or rejected claims enhance revenue management and financial performance.

By addressing payment issues promptly, providers can improve their financial outcomes and maintain a healthier revenue cycle.

Final Thoughts

The ERA in medical billing marks a significant leap forward in the healthcare industry’s journey towards digital transformation. The ERAs have become indispensable tools for healthcare providers that optimize payment-posting workflows, enhance accuracy, reduce administrative burden and optimize the revenue cycle management.

Finally, they help providers maximize the revenue and patient satisfaction with fast and accurate payment transfers.

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An Explanation of Benefits (EOB) is equally important for patients and providers. It helps identify billing errors in claims and enables providers to fix them to avoid claim denials. EOBs improve the overall effectiveness of billing and patient communication in medical practices.

The healthcare providers should properly check the details in EOB to understand the fixes. They must collaborate with patients to address the mistakes that the insurer pointed out in the document to streamline the billing process.

This guide helps providers understand the EOB in medical billing, its significance, components, workflow, and actionable steps to optimize billing processes by taking help from the EOB document.

What Is EOB In Medical Billing?

“EOB” in medical billing stands for “Explanation of Benefits.” The EOB is a document an insurance company sends to a covered individual (patient) explaining what medical treatments and/or services were paid for on their behalf. It details the services’ costs, how much was covered by the insurance, any discounts applied, and what the patient is responsible for paying.

This document is not a bill but a breakdown of how the insurance claim was processed and what portion, if any, the patient owes to the healthcare provider.

To understand the differences between an Explanation of Benefits (EOB) and a Medical Bill, see the comparison table below:

EOB Vs Medical Bill: A Comparison

Why Are EOBs Essential For Providers?

Explanation of Benefits (EOBs) are essential documents insurance companies provide that outline the services delivered to a patient, how much the insurance company paid, and what a patient has to pay the provider.

EOBs are essential for both patients and healthcare providers.

Here’s why they are essential for providers:

Ensures the Accuracy of Services and Providers 

EOBs list the services the healthcare providers deliver to their patients. Reviewing this document helps ensure that all listed services were provided and that there are no errors, such as services that a provider did not deliver to the patient. In this way, EOBs help providers avoid overcharges or fraudulent claims.

Identifies Errors in Billing and Insurance 

EOB helps providers compare a medical bill issued by an insurance company and the actual payment a patient pays. Providers can check the differences in billing information and insurance details. The provider can fix this issue if there is any inconsistency or mismatch between these two. So, EOBs can help providers address billing and insurance errors.

Assists in Payment Plans and Financial Options

Providers can review the costs (check the detailed breakdown costs mentioned by insurers) using EOBs in case of unexpected extra charges. The provider can easily discuss and negotiate the various payment options, such as setting up a payment plan or exploring other financial assistance options if the bills are too high for immediate payment.

Records Documentation for Disputes and Appeals

When a patient wants to appeal a decision made by the insurance company, he disputes a charge from the provider or clarifies tax deductions related to medical expenses. In this case, EOBs assist providers in sorting out the confusion of your patient. This contains a record of services and charges essential for appeals and disputes.

Ensure Compliance with Tax Regulations

EOBs can be used for tax purposes to verify medical expenses, especially when patients are itemizing deductions for healthcare costs on their tax returns. This can be important for ensuring providers claim the correct amounts and comply with tax regulations regarding medical expenses.

Components of an Explanation of Benefit (EOB)

There are various components of the Explanation of Benefit (EOB). Each provides a comprehensive overview of the claim and its financial implications.

Here’s what an EOB document may have:

➜ Patient Information: This section includes the insured individual or policyholder’s name, address, policy number, and other relevant details.

➜ Provider Information: This contains the name, address, and contact information of the healthcare provider who rendered the services.

➜ Claim Details: This consists of the services rendered and claim details, such as the service date, the description of the procedure or treatment, the claim no, and the billing codes.

➜ Billed Charges: The EOB shows the total charges billed by the healthcare provider for the services rendered. This amount represents the initial cost of the medical care before any adjustments or insurance coverage.

➜ Allowed Amount: The insurer wants to pay the maximum amount for the services rendered. This amount is the negotiated rate between the provider and the insurance company or based on the provider’s fee schedule.

➜ Insurance Coverage: These are the billed charges that the insurance company will cover. It includes deductibles, coinsurance, copayment amounts, and applicable limitations or exclusions.

➜ Patient Responsibility: This is the amount the patient is responsible for paying out-of-pocket. This may include copayments, deductibles, coinsurance, or any remaining balance after the insurance company’s payment.

➜ Payment Information: This is the information on the payment made by the insurance company to the healthcare provider. It includes the amount paid, the payment date, and any adjustments or write-offs applied.

➜ Remaining Balance: This is the remaining amount that the patient has to pay. This may include the non-covered services, the patient’s share of the allowed amount, or other outstanding charges.

Learn: How to read an EOB Document.

The Workflow of an EOB

The workflow of an Explanation of Benefits (EOB) is crucial for healthcare providers, ensuring accurate billing and timely payment for services rendered.

Let’s discuss the EOB workflow:

Patient Visit

• The EOB workflow starts when a patient visits a doctor and receives any service like a routine checkup, diagnostic test, etc.
• The physician documents the patient’s details, including the reason for the visit, any diagnosis made, and treatments provided.

Service Rendered

• The provider performs the necessary medical services based on the patient’s health needs.
• The physician ensures all services are medically necessary and correctly documented in the patient’s medical records.

Claim Submission

• The provider, or their billing office, compiles a detailed bill for services rendered and sends it to the patient’s insurance company via a clearinghouse.
• Provider submits all necessary service codes, patient information, and required documentation accurately.

Processing by Insurance

• Once the insurance company receives the claim, it processes it to determine the coverage and the amount payable.
• The provider may need to respond to queries from the insurance company or provide additional documentation if required.

EOB and Payment Issued

• After processing the claim, the insurance company issues an EOB to the provider, which details what has been covered, any deductions, and the final amount paid. Payment is usually made by check or electronic funds transfer (EFT).
• Review the EOB for accuracy, ensure the payment matches the EOB details, and address any discrepancies with the insurance company.

Electronic Payment Process for Providers

Healthcare providers need to make transactions secure and transparent. There are two ways they can complete the payment process electronically:

• Electronic Funds Transfer (EFT)
• Electronic Remittance Advice (ERA)

EFT and ERA help providers save time, reduce errors, and ensure compliance with HIPAA regulations. Additionally, providers can make secure and transparent transactions.

Providers can create the EOB as an electronic file, usually in a format called an 835, and can download the ERA 835 file from the clearinghouse.

Electronic Funds Transfer (EFT)

According to CMS.gov, Electronic Funds Transfer (EFT) transmits healthcare payments from a health plan to a healthcare provider’s bank.

An EFT transaction contains payment processing information such as:

• Amount being paid
• Names and identification information of the payer and payee
• Bank account information for the payer and payee (including routing and account information)
• Date of payment

Electronic Remittance Advice (ERA)

According to CMS.gov, electronic remittance advice, or ERA, is an explanation from a health plan to a provider about a claim payment. An ERA explains how a health plan has adjusted claim charges based on factors like:

• Contract agreements
• Secondary payers
• Benefit coverage
• Expected copays and coinsurance

Healthcare providers can connect an EFT with the services they provide to their patients using ERA. This helps providers and health plans track transactions, making the payment process secure and streamlined.

What Providers Should Do When They Receive EOB Receipt?

Upon receiving the ERA, the provider’s office should perform the following steps:

1). Payment Posting:

Payments must be applied to the correct patient accounts based on the information in the ERA. To efficiently post payments, the following details included in the EOB are essential:

• Payer Name and Address: The name and address of the insurance company making the payment.
• Patient Name: The name of the patient receiving the service.
• Provider Name and Address: The healthcare provider’s details.
• Member ID#: The policy identification number of the patient.
• Claim received Date: The date the payer received the claim from provider.
• Payment or denial date: The date the claim processed or denied by payer.
• Date of Service (DOS): The date service provided from provider to patient.
• CPT Code: Procedure code
• Billed Amount: The Amount for each service performed by providers.
• Claim Number: Number assigned by the payer for each claim.

2). Handle Secondary Claim

If the patient has secondary insurance, any remaining balances after the primary insurance’s payment should be billed to the secondary insurer.

• Allowed Amount: The amount suitable according to the payer for a specific service. AA = PA+ PR.
• Paid Amount: Paid Amount = Allowed Amount – Patient responsibility.
• Patient Responsibility: This is the balance percentage of reimbursement the patient must pay according to his policy with the insurance company. If they have one, the patient or his secondary insurance pays this.
• Write-off Amount: It is an amount that the provider waives off. Write-off amount = Billed Amount – Allowed Amount.

3). Billing Patient Balances

If there’s any amount due that is the patient’s responsibility and not covered by any insurance, the provider should bill the patient directly.

4). Address Claim Denials

If the insurer denies the claim, the provider must identify the reason for rejection and the denial code to resubmit the claim accurately.

Final Thoughts

Healthcare providers cannot ignore the importance of EOB in medical billing. It is equally essential for patients and providers.

EOB documents give providers a roadmap to address billing issues, such as claim errors, inaccurate insurance details, etc.

Choosing proper payment plans, utilizing fund transfer tools like EFT and ERA, and partnering with an experienced clearinghouse like BellMedEx streamlines the payment posting process.

In a nutshell, EOB makes the transaction process easy and enables you to focus on quality patient care, which is the ultimate goal of every provider.